Objective

In many European countries with ostensibly liberal abortion laws, women face legal restrictions to abortion beyond the first trimester of pregnancy, as well as other barriers to legal abortion, in particular shortages of providers willing and able to offer abortion due to poor training and to conscientious objection among physicians. The Council of Europe has recognized that conscientious objection can make access to safe abortion more difficult or impossible, particularly in rural areas and for low income women, who are forced to travel far to seek abortion care, including abroad. The WHO also highlights that delaying abortion care increases risks for women’s reproductive health. Despite the relevance of this topic from a public health and human rights perspective, the impact of procedural and social barriers to legal abortion on women in countries with ostensibly liberal abortion laws has not been studied by social scientists in Europe. This five-year research project is envisaged as a ground-breaking multi-disciplinary, mixed-methods investigation that will fill this gap, by capitalizing on previous, pioneer anthropological research of the PI on abortion and conscientious objection. It will contribute to the anthropology of reproduction in Europe, and particularly to the existing literature on abortion, conscientious objection and the medicalization of reproduction, and to the international debate on gender inequalities and citizenship, by exploring how barriers to legal abortion are constructed and how women embody and challenge them in different countries, by travelling or seeking illegal abortion, as well as their conceptualizations of abortion and their self perception as moral/political subjects. The project will be carried out in France, Italy and Spain, where the few existing studies show that women face several barriers to legal abortion as well as in the UK, the Netherlands and Spain, where Italian and French women travel to seek abortion care.

Periodic Reporting for period 2 - BAR2LEGAB (Women travelling to seek abortion care in Europe: the impact of barriers to legal abortion on women living in countries with ostensibly liberal abortion laws)

In Europe only a few countries have a very restrictive law on abortion, meaning that abortion is prohibited altogether or that it is only allowed (and possibly available) on very few grounds. In most countries, abortion is legal on general grounds. However, it remains restricted in different ways, which are mainly: legal restrictions to abortion beyond the 1st trimester of pregnancy, mandatory waiting periods/counselling, and shortages of providers willing & able to offer abortion due to poor or insufficient training, and conscientious objection among physicians. These barriers to access may lead women to seek abortion illegally, and have an unsafe abortion, or travel far from their area of residence to access legal abortion elsewhere. This is a topic of great significance in the EU debates about the long-term vision of health and social policy in Europe, and in particular about women’s rights to access to abortion and other reproductive health services, and health professionals’ right to conscientiously refuse to provide these services.Almost no study exists on abortion travel and illegal abortion in countries with relatively liberal abortion laws. However, there are some estimates on the number of illegal abortions in some countries (e.g. Italy). There are also some data on cross-country abortion travels in Europe, which include women living in the Republic of Ireland, where abortion was mainly illegal before December 2018, and women travelling abroad from countries with relatively liberal abortion laws, such as France, Germany, Belgium, and Italy. Moreover, in some countries (e.g. Italy, Spain, France) existing data show that women also travel from one province/region to the other to seek abortion care.The access to illegal practices of abortion has been largely studied in countries with restrictive laws (i.e. Poland). Some studies have also focused on abortion travel from countries with restrictive laws, notably from the Republic of Ireland to England. However, no studies and particularly no mixed-methods studies have studied the experiences of women living in countries with relatively liberal abortion laws with barriers to legal abortion, illegal abortion, and abortion travel. Why do these women travel? What are their experiences with abortion travel, and with abortion? Do they seek illegal abortion prior to travelling? In 2014 and 2015 Dr. Silvia De Zordo (who is the current Principal Investigator on this project), Dr. Joanna Mishtal and Dr. Caitlin Gerdts (Senior co-investigators) started to study the topic of abortion travel by collecting self-administered surveys in UK abortion clinics. This pilot-study showed that gestational age limits were the main reason for seeking abortion in England from countries with ostensibly liberal abortion laws (ie., Italy and France), and abortion travel represented an economic burden for many women. Based on this first study and on their different expertise, Dr. De Zordo and Dr. Mishtal, anthropologists, and Dr. Gerdts, epidemiologist, built up the present, larger, multi-disciplinary, mix-method study on barriers to access to legal abortion and abortion travel in Europe, focussing particularly on countries with relatively liberal abortion laws. Our current study is allowing us not only collect and analyse quantitative data, but combine an epistemological and public health approach to an anthropological one. In particular, adding an anthropological approach is allowing us to deepen the understanding of women's experiences with different kinds of barriers (legal – gestational age limits - procedural – conscientious objection or misinformation –social –abortion stigma) and with traveling to seek abortion care both cross-country and in their own country of residence.

The first phase of data collection, which started in June 2017, was aimed mainly at studying the phenomenon of cross-country abortion travel. Women from European countries with relatively liberal abortion laws were recruited from clinics in the UK, the Netherlands, and Spain. During this phase, we also carried out data collection on in-country abortion travel in Spain. Finally, we interviewed prominent abortion providers as well as key informants in the destination countries, in the origin countries of cross-country abortion travel, and also in Spain, in order to better understand barriers and the phenomenon of cross-and in-country abortion travel. We have thus far collected 291 surveys and 60 in-depth interviews on cross- country abortion travel in Spain, the Netherlands, and the UK. Of the interviews, 31 are with women from countries with restrictive abortion laws (Republic of Ireland, Poland, and Malta) and 29 with women from countries with relatively liberal abortion laws (Italy, France, Germany, Austria). For the part of the study on in-country abortion travel in Spain, we have collected 173 surveys and 51 in-depth interviews.As we just completed data collection in the UK and the Netherlands and are still recruiting in Spain for cross-country travel, we have not yet completed analysis for this phase. However, we have presented preliminary results at regional and international meetings and conferences. Additionally, the PI has co-organized panels and International Conferences on reproduction and abortion, and the team has discussed the preliminary results of this phase at meetings organized by organizations such as IPPF EN (International Planned Parenthood Federation European Network). The PI also co-edited with Maya Unnithan a Special Issue on abortion that was published by Global Public Health (Volume 13, Issue 6, 2018) and is working with the team on a number of papers that will be submitted for publication to anthropological and public health journals in Fall 2019. Additionally, the WHO, and specifically the “Maternal and Perinatal Health & Safe Abortion Team”, has invited the PI and the Senior Researchers to discuss the results of the study in June of 2019, with the potential that certain results will shape/be included in the new WHO “Guidance”. This shows the potential impact that this study may have in the domain of public health. The preliminary results of our project suggest that abortion travel is a significant phenomenon in Europe and the search for abortion care can be very difficult in spite of “liberal” abortion laws. Women face a number of legal (gestational age limits), procedural (lack of information/referral and conscientious objection), and social barriers (stigmatization within family and community) to access legal abortion, even in countries with relatively liberal abortion laws. These barriers lead women to travel far from where they live, posing a variety of hardships, including an economic burden associated with travel and the cost of the procedure abroad. They also lead to delays in obtaining abortion care, which represent a potential risk to women’s health. Our results also highlight the importance of key social agents for overcoming barriers to access, such as family planning organization, pro-choice websites and health professionals who support women’s reproductive decisions in their countries/regions of residence. Finally, our study raises questions about the impact of fragmented policies on abortion in Europe, the inequalities that these policies exacerbate, and the meanings of “safe” and “legal” abortion when travel is necessary. We will publish the results on the project’s website, which is meant to be a tool of dissemination of our findings to a wide audience, as well as a hub of information for women seeking abortion care in Europe - https://europeabortionaccessproject.org/.

This mixed-methods multi-disciplinary research project is a ground-breaking investigation that is providing new, fresh data on a topic that has been understudied by social scientists and therefore poorly understood by policy makers in Europe. It is therefore filling a gap in the existing literature and expanding knowledge on a topic that is relevant not only from an academic, social sciences perspective, but also from public health and human rights perspectives. The next phase of the study will focus mainly on barriers to legal abortion and in-country abortion travel in two countries of origin for cross-country abortion travel, Italy and France. The data collected during the next phase will allow to deepen the understanding of the barriers that women face when they seek abortion care in countries with relatively liberal abortion laws and the reasons why they choose to travel either within the borders of their own country, or abroad. It will also allow better understand the phenomenon of illegal abortion in countries with relatively liberal abortion laws, as women may try to end their pregnancy by using illegal methods before travelling. This is a highly relevant topic from a public health and human rights perspective. The results of the next phase of the study will be published on the project website and in anthropological and public health journals. They will also be presented and discussed at academic and non-academic conferences and meetings. Our main goal is to contribute not only to the academic debate on these relevant topics, but also to the legal debates on women’s human rights, and particularly women’s reproductive rights, as they have been defined at important international Conferences in Cairo and Beijing in the 1990s. The data collected through this research project may help to discuss and inform policy decisions aimed at improving women’s access to timely, good quality abortion care in Europe.